RU2655832C2 - Method of surgical treatment of patients with total scar facial deformities - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, traumatology, plastic surgery, combustiology, and can be used in patients with total cicatricial deformities on the face of various origin. For this in one operation all cicatricial deformations are eliminated, excising the entire scar-altered skin on the face. Then autoplasty is performed with a full-length full-length autograft of the appropriate size with the formation of slits for the eyes, mouth, and nose in it. After that vacuum system of Suprasorb CNP Easy Dress from Lohmann&Rauscher is used.

EFFECT: method provides reduction in the risk of repeated operations by eliminating all cicatricial deformities on the face in one operation, replacing the deformation with one free full-layer cutaneous autograft, which minimizes the number of graft joints with surrounding tissues, while the use of a vacuum bandage on the head after performing this operation allows the patient to be given any position in the bed without the possibility of bandaging and disruption of the bandages.

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Description

The present invention relates to medicine, namely to surgery, traumatology, plastic surgery, combustiology, and can be used in patients with gross, total cicatricial deformities on the face of various origins.

The problem of burns to date remains one of the most relevant and complex in modern medicine. First of all, this is due to the significant spread of burns among the population, and therefore, without exaggeration, it can be called the modern traumatic epidemic of densely populated cities and industrialized countries of the world (A.V. Vorobyov, S.P. Peretyagin, S.A. Bukhalov et al., 2008). The outcome of a burn injury depends on many causes, the main of which are the depth of the burn, its area, localization and age of the patient. An active and targeted treatment program plays an important role. Victims with extensive burns, as a rule, develop various complications that subsequently cause partial or complete disability and often deprive the victim of the opportunity to take care of themselves (V.V. Yudenich, V.M. Grishkevich, 1986). A special place among all localizations of deep burns is burns localized on the face. Deep burns on the face, healing spontaneously or treated with a skin transplant, almost always result in the development of pathological scars, especially in the area with mobile tissues and natural openings. With deep burns of the face, cicatricial deformities occur in the form of eyelid inversions, microstomies, deformations of the auricles, nose and osteonecrosis of the cranial vault, leading to disability of patients. Cicatricial deformations on the face disfigure patients, thereby complicating their social adaptation and life in society.

An analogue of the present invention is the method of plastic eyelid eversion with split skin, described by V.V. Yudenich, V.M. Grishkevich (Guidelines for the rehabilitation of burned people. - Moscow, "Medicine" 1986. - 110-111 p.). A thorough and careful dissection of cicatricial cords is performed, the length of the incision is determined by the degree of contraction and spread of the scars, and the incision may extend beyond the palpebral fissure. The width of the formed wound reaches 2-3 cm, and when traction is held, the corrected eyelid should close the entire eyeball. The mobilized eyelid is fixed in the stretched position by stitching through the skin with stitches with the holders of the eyebrow region with plastic surgery of the lower eyelid or the zygomatic bone region with correction of the upper eyelid. After this, the wound is closed with split skin, 0.3 mm thick, fixing it with sutures. Both eyes are bandaged even if the intervention was on the same eyelid. The first ligation after 5 days, while the unoperated eye is freed. On the 7th day, the eyelid is released from the fixing sutures and only by the 10th day can the bandage be removed from the operated eye.

The disadvantages of the method include:

1. In one operation, only cicatricial deformities of the eyelids are eliminated.

2. After performing free plastic surgery with a split graft, at the junction of the surrounding tissues with the graft, repeated cicatricial deformations may form in the future.

3. Uneven pressure when applying bandages.

4. Uncontrolled pressure on head wounds.

5. The ability to form hematomas under grafts when applying bandages after plastic surgery.

6. The possibility of slipping the bandages when the patient moves his head.

As the closest analogue, we adopted the surgical tactics of treating patients with the consequences of facial burns, described by N.L. Korotkova, S.Yu. Ivanov (Journal “Annals of Plastic, Reconstructive and Aesthetic Surgery.” - Moscow, Society of Plastic, Reconstructive and Aesthetic Surgeons 2012. - No. 4 10-17 pp.). In order to optimize surgical treatment, the authors proposed a working classification of post-burn facial deformities. Planning for the treatment of cicatricial deformities involves three stages: 1st stage: assessment of the localization, prevalence and degree of involvement of facial structures in the pathological process; 2nd stage: determining the timing and sequence of reconstructive interventions; 3rd stage: the choice of method of skin plastics. The main task in eliminating facial defects is to restore the skin from tissues similar in color and structure. The best plastic material for its characteristics recognized the tissue of neighboring areas of the face. In the presence of a microstomy, the authors propose using plastic with local tissues - flaps on the feeding legs (patent No. 2269306). To eliminate cicatricial deformity of the nose and epicanthus of the inner corners of the eyes, leaf flaps are cut out in the nose region with bases facing the inner corners of the eyes (patent No. 2394504). The scars between the tops of the flaps intersect with a transverse section, forming vertical flaps with a proximal and distal base. All the flaps are mobilized, the flaps are sewn together with the tops, eliminating the folds of the epicanthus. A vertical flap with a proximal base is sutured to the lateral sides of the flap sewn together. Then excised scars on the back of the nose and in the area of the wings, as well as a vertical scar flap with a distal base. The resulting wound defect after excision is closed with a full-layer skin graft. The disadvantages of the method include:

1. Multiple cicatricial deformities are eliminated in stages, in several operations.

2. After performing skin grafting of each defect separately at the junction of the surrounding tissue with the graft in the future, repeated cicatricial deformities may form.

3. For plastic surgery with local tissues, scar flaps are used.

4. When performing multi-stage operations, functional disorders are eliminated, but the scarring of the face remains.

Tasks:

- improve the method of surgical treatment of total cicatricial deformations of the face;

- improve the functional and cosmetic results of surgical treatment of total cicatricial deformations of the face;

- to ensure uniform tight pressure on the graft with autodermoplasty on the head;

- to achieve the elimination in one operation of all cicatricial deformations of the face and replace all the scarred skin.

The essence of the invention is the following: in one operation, all cicatricial deformities are eliminated, all scarred skin on the face is excised, and autoplasty is performed with a solid full-layer autograft of the appropriate size with the formation of slits for the eyes, mouth, nose, followed by the use of a vacuum bandage.

Technical result: in one operation, it is possible to eliminate all cicatricial deformations on the face, remove all cicatricial skin and replace it with new skin - one free full-layer skin autograft, as well as minimize the number of joints of the graft with surrounding tissues, which reduces the risk of repeated operations . When using a vacuum dressing on the head after performing this operation, the patient can be given any position in the bed without fear of displacement of the dressings and violation of their integrity.

The implementation of the method of treatment of a patient with total cicatricial deformations of the face is as follows. In the operating room, at first the patient is given a gastric tube, under the control of bronchoscopy, a dilated tracheostomy is performed. After standard processing of the surgical field, blepharography is performed, then the nasal and oral cavities are tightly plugged, and the upper respiratory tract is completely tight. After all these manipulations, a bordering incision is made, perpendicular to the surface of the skin of the face at the border of the scarred and healthy skin, after which the entire mass of scars is gradually removed using a scalpel, gradually mobilizing the scar array, the scars are dissected to viable non-scar tissue, and it is important if possible, excise all scar tissue. The bilateral microstomy is eliminated by means of trapezoidal flaps from the oral mucosa. Cicatricial eversion of the upper and lower eyelids is eliminated. Make hemostasis, pressing the wound with dressings with a solution of adrenaline for 3-5 minutes. A skin defect is measured, and on a healthy area of the skin, the expected donor site of the appropriate size is marked. With a scalpel on a healthy area of the skin, a bordering incision is made of the required size. A skin autograft is taken onto the holders and excised with a scalpel to the subcutaneous tissue with the condition that the mosaic sections of the lower layers of the dermis are preserved; or in subcutaneous fat. From the inside of the dermis, the autograft is treated with a dermatome with excision of a thickness of 0.1 mm of the dermis - to align it from the inside. The thickness of a full-layer whole skin autograft is 1-2 mm, depending on the thickness of the dermis at different donor sites of the body. After 9-10 days, when granulation tissue is formed on the donor site, an electrodermatome selects free split skin autografts with a thickness of 0.2-0.3 mm on free skin areas, is perforated with a 1: 2 coefficient, and placed on the donor site of a full-layer autograft. After the graft is treated, plastic surgery is performed on the whole free full-layer skin autograft of the wound formed after removal of the cicatricial masses of the face, with the formation of cuts for the nose, mouth, eyes. Bandages are tightly laid with “Kerlix AMD gauze” tiles, then the head is tightly bandaged in 2-3 rounds with a Kerlix AMD gauze bandage. After bandaging the patient’s head, a special sterile bag for Lohmann & Rauscher Suprasorb CNP Easy Dress vacuum systems is put on, with a reserve for healthy skin, the bag is hermetically fixed to the skin with SuprasorbF film, then with the help of a scalpel or scissors in the bag, I form a port commensurate with the flat drainage, after which, through the drainage connector, the drainage tube connects the vacuum of the apparatus to the connecting hose, which, in turn, connects to the exudate collector (container). The device is set to the necessary settings to create negative pressure, depending on the indications for the treatment of this wound. When creating a vacuum on the head, the bandage is compacted, the corresponding indicators on the normal functioning of the device light up on the display of the device. The patient is transported to the ward.

According to this method, 1 patient with total cicatricial deformities on the face was operated on under clinical conditions.

Example 1. Patient W., 20 years old, was admitted to the burn department. GBUZ-NII KKB №1 named after prof. S.V. Ochapovsky 07/18/2016 with a diagnosis of Post-burn hypertrophic deforming facial scars, bilateral microstomy, bilateral inversion of the upper and lower eyelids, cicatricial contraction of the right auricle (Fig. 1). The patient was taken to the operating room, under endotracheal anesthesia, after the standard treatment of the surgical field, the dilated tracheostomy was performed according to the standard procedure adopted by the clinic, then a gastric tube was installed, nasal and oral tamponade was performed, and blepharography was performed. After all these manipulations, a bordering incision is made, perpendicular to the surface of the skin of the face along the border of scarred and healthy skin, after which the entire mass of scars is gradually removed using a scalpel, gradually mobilizing the scar massif, the scars are excised to the superficial fascia. The cicatricial ectropion of the right auricle was removed, the microstomy, the ectopic eyelids were removed, the nose was released from the cicatricial, epicanthus folds were removed (Fig. 3). The appearance of the wound after excision of the entire scarred skin (Fig. 4). Hemostasis. A skin defect on the face and abdomen was measured, and on the healthy area of the skin, the expected donor site was marked corresponding to the size of the wound on the face. A scalpel on a healthy area of the skin produced a bordering incision of the required size. The skin autograft is taken on the holders and excised with a scalpel to the subcutaneous tissue. From the inside of the dermis, the autograft was treated with a dermatome with excision of a thickness of 0.1 mm of the dermis - to align it from the inside (Fig. 2). The thickness of a full-layer whole skin autograft is 1-2 mm. The wound on the face is covered with a prepared autograft (Fig. 5). Autoplasty was performed with openings for the eyes, mouth, and nose, the edges of the graft were stitched with an upholstered continuous suture with matching “butt to butt” (Fig. 6). Apply bandages from gauze Kerlix AMD moistened with a water solution of chlorhexidine, the head is tightly bandaged in 2-3 rounds with a bandage from gauze Kerlix AMD. After applying the bandages to the head, a special sterile bag for vacuum systems Suprasorb CNP Easy Dress is put on, the bag is fixed to the skin with Suprasorb F film, then a port for drainage is formed in the bandage, and the vacuum apparatus is connected through the drainage connector and set the appropriate pressure parameters (Fig. 7 ) The vacuum dressing is removed after 2 days, there is a tight fit of the graft with the bottom of the wound, the absence of hematomas under the graft. Complete graft engraftment is observed 12-14 days after surgery. In one operation, the patient eliminated all cicatricial deformities: the release of the right auricle from the scar tissue; excision of scar tissue of the nose; bowing of the nasal passages; elimination of the eversion of the upper right eyelid; elimination of the eversion of the upper left eyelid; elimination of the eversion of the lower right eyelid; elimination of the eversion of the lower left eyelid; elimination of mouth microstomy on the right; elimination of mouth microstomy on the left; plastic with local tissues of the inner corner of the right eye; plastic with local tissues of the inner corner of the left eye; plastic with local tissues of the outer corner of the right eye; plastic with local tissues of the outer corner of the left eye; plastic with local tissues of the corner of the mouth on the right; plastic with local tissues of the angle of the mouth on the left. A good result is noted before discharge, the patient is pleased with the new face (Fig. 8). Due to the application of this method of surgical treatment of patients with total cicatricial deformities of the face in one operation and one hospitalization, the patient receives a new face, all scarred skin and cicatricial deformities are eliminated.

Claims (1)

A method of surgical treatment of patients with total cicatricial deformities of the face, including the elimination of cicatricial deformities, performing free skin grafting, characterized in that all cicatricial deformities are eliminated in one operation, all the scarred skin on the face is excised and autoplasty is performed with a full-layer autograft of the appropriate size with the formation there are slits for the eyes, mouth, nose, followed by the use of the Suprasorb CNP Easy Dress vacuum system from Lohmann & Rauscher.

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